parodontology lambeau

1. THE PERIODONTAL FLAP
Rational, Indications and Techniques

2. DEFINITION OF PERIODONTAL
FLAP
• Periodontal Flap is a section of gingiva
and/or mucosa, surgically separated from
the underlying tissues to provide visibility
of and access to bone and root surfaces,
such as those associated with deep
pockets or furcations.

3. OBJECTIVES OF SURGICAL
PROCEDURES
• Improvement of the prognosis of teeth
and their replacements.
• Improvement of esthetics.
• The surgical phase consists of various
techniques that can be used for the pocket
therapy and for the correction of related
morphologic problems, namely
mucogingival defects.

4. GOALS OF FLAP PROCEDURES
• To expose root surfaces that are not accessible, such
as those associated with deep pockets or furcations,
in order to improve the efficiency of scaling and root
planing.
• The surgical reduction or elimination of the
periodontal pocket (resective pocket surgery).
• The induction of adaptation and new attachment
and bone regeneration in periodontal pockets
(regenerative pocket surgery).
• The correction of gingival and mucogingival defects
and deficiencies.

5. Pocket Reduction Surgery
• Resective: gingivectomy, apically
displaced flap and undisplaced flap with
or without osseous resection.
• Regenerative: flaps with grafts, guided
tissue regeneration, and coronally
positioned flaps.

6. Correction of Anatomic –
Morphologic Defects
• Plastic surgery techniques to widen
attached gingiva: free gingival grafts,
etc…
• Esthetic surgery: root coverage, and re-
creation of gingival papillae.
• Preprosthetic techniques: crown
lengthening, ridge augmentation, and
vestibular deepening.

7. Basic Principles Of Flap Surgery
Classification of flaps:
1. According to the thickness of the flap
2. According to placement of the flap.
3. According to the management of the
interdental papilla.

8. 1. According to the thickness of the
flap
Depending on whether bone is exposed or not, flaps can
be classified as:
• Full Thickness Flaps (Mucoperiosteal Flaps): All the
soft tissues including the periosteum is reflected to
expose the underlying bone. The procedure is indicated
when resective osseous surgery is contemplated.
• Partial or Split-Thickness Flaps (Mucosal Flaps):
Reflection of only the epithelium and a layer of the
underlying connective tissue, the bone remains covered
by a layer of connective tissue including the
periosteum. It is indicated when the flap is to be
positioned apically or when the Dentist does not desire
to expose bone.

9. 2. According to the Placement of the
Flap
Based on the flap placement at the end of the
procedure, flaps can be classified as:
• Non-displaced flaps: When the flap is sutured in its
original position (access flaps).
• Displaced flaps: The flap is sutured in a more apical
(apically positioned flap) or coronal position
(coronally positioned flap) to its original position.
Palatal flaps cannot be displaced.

10. 3. According to the Management of
the Papilla
Flaps can be conventional or papilla preservation flaps:
• Conventional Flaps: splitting the papilla into facial half and
lingual or palatal half. Conventional flaps include modified
Widman flap, the undisplaced flap and apically displaced
flap.
The conventional flap is used when:
• The interdental spaces are too narrow to permit the
preservation of the papilla.
• When there is a need for displaced flaps.
• Papilla Preservation Flaps: entire papilla is incorporated into
one of the flaps.

11. INCISIONS
• Horizontal Incisions: are made along the gingival
margin either laterally to the margin (internal
bevel incision) or in the pocket (crevicular
incision):
A. Internal bevel incision = reverse bevel incision:
Is the basic incision allowing the flap to be
reflected to expose the root and alveolar bone. It
starts at a distance of 0.5-1mm from the gingival
margin and extends full depth to the alveolar
bone.

12. INCISIONS
B. Crevicular Incision (intrasulcular incision):
Is the second incision that will enable with
the first internal bevel incision the
removal of the part of gingival tissue
located in between the two horizontal
incisions.

13. INCISIONS
C. Interdental incision:
Is the third incision (Orban knife is usually
utilized for this incision) that is done after
slight elevation of the flap with a
periosteal elevator introduced in the
internal bevel incision line.

14. INCISIONS
• Vertical incisions:
• Vertical or oblique releasing incision can be used at one or
both ends of the horizontal incision.
• If the flap needs to be displaced, the incision(s) needs to
extend beyond the muco-gingival line.
• Incision(s) should be made at the line angle of a tooth to avoid
incising over the root or the papilla.